Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2853

2. Registrant Information.

Registrant Reference Number: 2012-IR-09

Registrant Name (Full Legal Name no abbreviations): E.I. du Pont Canada Company

Address: 7070 Mississauga Road

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: LN 5M8

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

01-AUG-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

6. Date incident was first observed.

11-JUL-12

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Imprelis Herbicide

• Active Ingredient(s)
  • AMINOCYCLOPYRACHLOR

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>6 mos / > 6 mois

11. List all symptoms

System

• General
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Other
  • Specify - inflamed bowel disease

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify animal ate grass that was treated with imprelis herbicide

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Dog was exposed 7 months prior to death. Dog passed away in December. Dog would eat the grass that was sprayed with Imprelis. Big oak tree was killed by Imprelis as well. Dog was diagnosed with inflamed bowel disease by vet.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

Medical outcome was that it was an unrelated effect. As per the MSDS "no specific intervention is indicated as the compound is not likely to be hazardous".